Medicare Part D Prescription Drug Benefit
2012 SeniorCare Complete Member Materials
- Summary of Benefits (.pdf)
- Member Guide (.pdf)
- Evidence of Coverage (.pdf)
- Primary Care Clinic Network Listing (.pdf)
- Provider Directory (.pdf)
- Comprehensive Formulary (.pdf)
- Supplementary Drug List (.pdf)
- CMS Best Available Evidence Coverage (web)
- 1864 H2419 Part C Plan Rating (.pdf)
- 1865 H2419 Part D Plan Rating (.pdf)
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For people with Medicare, SeniorCare Complete includes Medicare Part D (prescription drug) coverage. The SeniorCare Complete Medicare Part D Comprehensive Formulary (list of covered drugs) is shown on this page in different formats. You may search the online “Check the Drug List” (below the Member Materials list) to see what is covered. You may also download and view or print a copy of the Comprehensive Formulary from the Member Materials box on the right side of this page. Sometimes the list of covered drugs changes, so call Member Services if you have questions.
If your current prescription drugs are not on the list of covered drugs or are limited in some way, SCHA has a General Transition Notice (.doc) which explains what happens in certain situations.
SeniorCare Complete’s pharmacy network equals or exceeds CMS requirements for pharmacy access in your area. Our network has over 60,000 pharmacies throughout the United States, with over 1100 pharmacies in Minnesota. You can find network pharmacies here in two ways. You may download and view or print a copy of the pharmacy section from the Provider Directory located in the Member Materials box on the right side of this page. You may also search the online “Find a Pharmacy” listing (below the Member Materials list) to find a pharmacy near you.
If you have Medicare, and depending on your income and institutional status, your prescription drug copay will be:
- For generic drugs: $0, $1.10 or $2.60
- For brand name drugs: $0, $3.30 or $6.50
You must use network pharmacies to access your prescription drug benefit, except under certain circumstances. For more information about this, out-of-network coverage, or if your pharmacy leaves the network see your Certificate of Coverage.
Free printed copies of both the Comprehensive Formulary (List of Covered Drugs) and the Provider Directory are available upon request by calling Member Services.
Part D: Exceptions and Appeals Information
Click here to go to MyPrime.com for information, forms, and instructions regarding:
- Formulary Exceptions: Used to request coverage for a drug not on the formulary (not covered) or to request a tier exception
- Prior Authorizations: Required on some medications before your drug will be covered
- Step Therapy: Requires the previous use of one or more drugs before coverage of a different drug is provided
- Appeals: If you or your doctor does not agree with the outcome of the initial coverage determination - you or your doctor may appeal the decision by having your doctor request a re-determination
Medicare’s “Extra Help” Program
Medicare provides Extra Help to pay prescription drug costs for people who have limited income and resources.
As long as you are eligible for Medical Assistance, you qualify for and are getting Extra Help paying your prescription drug plan costs. You do not need to do anything further to get this Extra Help.
If you have questions about Extra Help, call:
- 1-800-MEDICARE (1-800-633-4227). TTY users should call 1-877-486-2048, 24 hours a day, 7 days a week;
- The Social Security Office at 1-800-772-1213, between 7 a.m. to 7 p.m., Monday through Friday. TTY users should call 1-800-325-0778; or
- Your State Medicaid Office, the Minnesota Department of Human Services at 651-431-2670 (Twin Cities metro area) or (800) 657-3739 (outside Twin Cities metro area) TTY users should call 1-800-627-3529 or 711. This number requires special telephone equipment and is only for people who have difficulties with hearing or speaking.
Links to Additional Information from the Centers for Medicare & Medicaid Services (CMS)
- CMS Best Available Evidence Coverage (CMS website .pdf)
- Request for Medicare Prescription Drug Coverage Determination form (CMS website .pdf)
- Medicare Part D Coverage Determination Request Form (CMS website .pdf)